The impact of an educational intervention, the New GP Contract and NICE guidelines on anti-epilepsy therapeutic drug monitoring

BACKGROUND Since the early 1970s therapeutic drug monitoring (TDM) of anti-epilepsy drug (AED) levels has been available to assist in the review process of patients with epilepsy. Routine blood levels were not part of the Quality and Outcomes Framework in the New GP Contract, neither have they been generally recommended in National Guidelines (NICE and SIGN) for the management of patients with epilepsy. AIM To assess the impact of an educational intervention, the New GP Contract and NICE guidelines on the number of requests for TDM. DESIGN Retrospective study. SETTING 39 general practices serving Chester (13), the Rural area surrounding Chester (13) and Ellesmere Port (13). METHODS An educational intervention took place in the individual Chester practices between December 2001 and March 2003. For the Rural and Ellesmere Port practices there was one combined event in March 2004 and in March 2007, respectively. Practices were encouraged, not to routinely request TDM, except in certain circumstances. The number of TDM requests for Chester, Rural and Ellesmere Port were obtained from the local laboratory in Chester, plus other nearby hospitals, to provide control groups. MAIN OUTCOME MEASURES The number of TDM requests from primary care for Chester, Rural, Ellesmere Port, Wirral, Crewe, Warrington and Wrexham, April to April, 2002 through to 2008, where available. RESULTS There has been a fall in the number requests in all districts. The most significant falls were in Chester (47%), Rural (34%) and Ellesmere Port (47%), and corresponded to the time of their educational intervention. The fall has been less marked in Wirral (25%), Crewe (27%), Wrexham (10%) and Warrington (9%). In 2004, the first year after the introduction of the New GP Contract, TDM in Chester and the Rural fell significantly, while those in Ellesmere Port, Wirral, Crewe and Wrexham increased. TDM dropped significantly in Ellesmere Port in the year after their educational intervention. Despite the valproate assay being clinically unhelpful there were still 611 requests in the areas studied in 2007/2008. CONCLUSION The overall number of TDM requests has fallen since 2004 with the introduction of the New GP Contract and National Guidelines on the management of patients with epilepsy. The reduction has been more significant in areas where the changes were supplemented by an educational intervention. PCTs should endeavour to facilitate the introduction of National Guidelines with a supportive educational process, facilitated by educators with an interest and stake hold in those specific dillnesses. There is a significant cost to the NHS of inappropriate requests for TDM. Further study is required to quantify the indications for current requests for TDM.